I'D BEEN A HOME healthcare nurse for only a few weeks when I met Sam. At the time, I was still struggling to adjust to a new position and an entirely different kind of nursing. Working in an ED for 6 years had shaped me into a quick-moving, no-nonsense, assertive nurse accustomed to a significant amount of control at work. Home healthcare was a shock-not only did I lack control over my environment, I struggled just to find the right address. That's one reason I remember Sam so well. He was so hard to find, but after I met him, so hard to forget.

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All alone

Sam, 80, was a retired veteran who lived alone. He'd moved to our community to be near his widowed sister. When she died, he was left with no family. Except for his landlord, who visited rarely, he had no one to help him, or even to check in on him.

Sam came to us as a patient because he'd fallen and lain on the floor of his camper for 2 days, resulting in hospitalization. Discharge planners tried to have him consider long-term-care facility placement, but he refused. He didn't have much left in the world except his independence, and he was steadfastly holding onto it. Sam was discharged with a referral for home healthcare to evaluate his home situation and monitor his adherence to his treatment plan.

"This is my home"

As a career military man, Sam was very independent. I had trouble finding him because he lived in a tiny camper with no address markings.

Once I found the camper, I knocked on the door and Sam yelled at me to come in. I'd never been in such a small living area: one room with a twin bed, kitchenette, and rocker, plus a tiny bathroom.

Sam was sitting in the rocker. After introducing myself I performed a physical assessment, followed by an assessment of his home environment. I found only cold cuts and water in his refrigerator. He told me he was hoping his landlord might check in on him so he could get some groceries. His stove didn't work, although I doubted he could stand long enough to cook.

Sam got up from the rocker with some difficulty. I was thankful the camper was small, saving him steps. I brought up the subject of a long-term-care facility or assisted living facility, but he'd have nothing to do with that. "I will never live in a nursing home," he said emphatically. "This is my home."

In all my years working in the ED, I'd never considered the environment people were going home to when they left. To me, it was evident that a long-term-care facility was the best option for Sam-but obviously this wasn't evident to him. So instead of trying to change his mind, I turned my attention and energy to supporting his choices.

A new focus

That afternoon, I made arrangements for Sam's prescriptions to be filled. I went back to the office and arranged for him to have meals delivered through Meals on Wheels, a housekeeper for an hour a week through the Council on Aging, and a nursing assistant to help him twice a week with his activities of daily living. I had a walker delivered so he could move about more safely and arranged for him to have a call alert in case he fell again. His landlord agreed to respond in an emergency.

That was the beginning of a relationship that lasted until his death a year later. Every time I visited Sam, he'd start our conversation with, "No, I'm not going to the nursing home"-just to remind me who was boss. Sam never let me forget that my job as a patient advocate is to support my patients' decisions as best I can-even though I might not agree or make the same choices for myself.

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